ORS Refund Application (R0311C)

Retirement (ORS)

Use this form if your employment has terminated and you want to withdraw your pension contributions on account with the retirement system. This may forfeit your rights to a future pension with the retirement system. See refund instructions before completing. If you are eligible for a pension and married, you and your spouse must complete the Refund Certification and Spousal Waiver (R0902C).

Member information

Last name

First name

M.I.

Date of birth

Member IDEnter your ORS member ID. Do not enter a Social Security number on this page — if you do not have your member ID, leave this blank and write it on the printed form.

Mailing address

City

State

ZIP code

Reporting unit last worked

Employment end date

Home telephone

Email address

Section I — Refund election

Select one option. If you choose option 1 or 3, 20 percent of the previously untaxed contributions and interest will be withheld as federal income tax.

Refund election

Option 1 — I wish to have my refund paid directly to me.Option 2 — I wish to have all previously untaxed pension contributions and interest transferred directly into a qualified retirement plan or individual retirement account, and have any previously taxed contributions refunded to me.Option 3 — I wish to have a stated amount of my previously untaxed pension contributions and interest transferred into a retirement plan or individual retirement account. I wish to have the balance paid directly to me.

Amount to transfer (USD)

Plan or IRA is held at

Section II — Tax withholding

ORS will automatically withhold federal income taxes from any amounts paid directly to you.

Michigan income tax

Withhold Michigan income tax from my refund.

Sections III, IV and V — completed on paper

Three parts of this application cannot be completed online. After you submit, download your pre-filled R0311C and obtain: Section III from your financial institution's plan administrator (only if you selected option 2 or 3); Section IV from the payroll office of your last employer (only if your employment ended within the last 6 months); and Section V, your own signature, made in person before a notary public. Mail the completed form to the Office of Retirement Services, P.O. Box 30171, Lansing, MI 48909-7671, or fax it to (517) 284-4416.

Did your employment end within the last 6 months?

Acknowledgements

I understand that taking a refund may forfeit my rights to a future pension with the retirement system, and that once a refund is processed it cannot be cancelled.

I understand this online form does not replace the signed R0311C, and that my application is not filed until ORS receives the printed form signed before a notary public.

I have read the district privacy notice and consent to the processing of this information.